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Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers and 2 of 4 smoke barrier walls were maintained to provide a one hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all 200 hall occupants.

Findings include:

Based on an observation with Maintenance Man #1 on 07/21/15 from 10:46 a.m. to 10:49 a.m., the following unsealed penetrations were noted:
a) a three inch hole above the ceiling tile on the 2nd floor stairwell near resident room 203 was unsealed.
b) one of nine sprinkler heads was missing an escutcheon near resident room 203.
c) multiple ceiling penetrations in the Basement Boiler room including a two inch penetration around conduit, four inch, three inch, and a two inch drywall cut unsealed penetrations. Based on interview at the time of each observation, the Maintenance Man #1 acknowledged each aforementioned condition.

3.1-19(b)

Based on observation and interview, the facility failed to ensure the corridor doors entering 1 of 1 kitchen and 1 of 1 dry foods storage room, used to store combustibles and measuring over 50 square feet in size, were provided with a self closing device and positive latching hardware. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with Maintenance Man #1 on 07/21/15 at 11:03 p.m., the two corridor doors entering the kitchen contained self closing devices, but only had manual latching hardware into the frame. Based on interview at the time of observation, the Maintenance Man #1 acknowledged the aforementioned condition.

3.1-19(b)

Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.2.3.2.4.2 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet on of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
This deficient practice was not in a patient care area but could affect both basement smoke compartments.

Findings include:

Based on an observation with Maintenance Man #1 on 07/21/15 during the facility tour between 10:11 a.m. and 12:19 p.m., at the basement two hour fire barrier doors above the ceiling tile there was an unsealed penetration above the ceiling tile measuring four inches around a hot water line. Based on interview at the time of observation, the Maintenance Man #1 acknowledged the aforementioned condition.