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Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101: 19.1.6.3.

Findings include:

The fifth floor east wing above the ceiling tile by the cross-corridor doors had an 8 " x 12 " wall opening that would not resist the passage of fire and smoke.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain smoke barrier assemblies of the facility in accordance with NFPA 101: 18.3.7.3

Findings include:

Above the ceiling tile of cross corridor door assemble by room #566 had two 1 " wall openings that would not resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain approximately 2 of 9 corridor fire doors assemblies of the facility in accordance with NFPA 101: 18.3.6.1 and 7.2.1.8.2.

Findings include:

The cross corridor doors assemble by rooms #579 and #566 had ? " gap between the doors that would not resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 18.3.2.1 and 7.2.1.8.

Findings include:

1. The maintenance shop double door assembly had ? " gap between the doors that would not resist the passage of smoke and fire.
2. Fire rated door assembly to rooms #454, #365 and #354 were not properly labeled to be listed as a rated assembly.
3. Resident rooms #356, #377 and #375 were being used as storage rooms and did not have ? hour fire-rated doors.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the exits to be readily accessible at all times in accordance with NFPA 101: 7.2.1.5.1.

Findings include:

The pharmacy entrance door had double locks that did not release as a single action lock to the path of egress.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the emergency lighting system in accordance with NFPA 101: 18.2.9.1., 7.9 and CMS regulations.

Findings include:

The emergency electrical switch gear room did not have battery operated emergency task lighting.

Based upon observations made in the presence of the plant manager on 6/27/17, it was determined that the facility did not maintain fire portable fire extinguishers in accordance with NFPA 101: 18.3.5.6, 9.7.4.1 and NFPA 10 6.2.1 regulations.

Findings include:

The kitchen area was lacking a portable fire extinguisher in addition to the required K type fire extinguisher.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101: 19.1.6.3.

Findings include:

The fifth floor east wing above the ceiling tile by the cross-corridor doors had an 8 " x 12 " wall opening that would not resist the passage of fire and smoke.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain smoke barrier assemblies of the facility in accordance with NFPA 101: 18.3.7.3

Findings include:

Above the ceiling tile of cross corridor door assemble by room #566 had two 1 " wall openings that would not resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain approximately 2 of 9 corridor fire doors assemblies of the facility in accordance with NFPA 101: 18.3.6.1 and 7.2.1.8.2.

Findings include:

The cross corridor doors assemble by rooms #579 and #566 had ? " gap between the doors that would not resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 18.3.2.1 and 7.2.1.8.

Findings include:

1. The maintenance shop double door assembly had ? " gap between the doors that would not resist the passage of smoke and fire.
2. Fire rated door assembly to rooms #454, #365 and #354 were not properly labeled to be listed as a rated assembly.
3. Resident rooms #356, #377 and #375 were being used as storage rooms and did not have ? hour fire-rated doors.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the exits to be readily accessible at all times in accordance with NFPA 101: 7.2.1.5.1.

Findings include:

The pharmacy entrance door had double locks that did not release as a single action lock to the path of egress.

Based upon observations made in the presence of the plant manager on 6/27/12, it was determined that the facility did not maintain the emergency lighting system in accordance with NFPA 101: 18.2.9.1., 7.9 and CMS regulations.

Findings include:

The emergency electrical switch gear room did not have battery operated emergency task lighting.

Based upon observations made in the presence of the plant manager on 6/27/17, it was determined that the facility did not maintain fire portable fire extinguishers in accordance with NFPA 101: 18.3.5.6, 9.7.4.1 and NFPA 10 6.2.1 regulations.

Findings include:

The kitchen area was lacking a portable fire extinguisher in addition to the required K type fire extinguisher.