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Based on observation and interview, the facility is not assuring that one of seven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 8 residents, staff, and visitors in the facility. The facility has a capacity of 25 with a census of 8.

Findings include:

1. Observation and interview on 06/02/2015 at 2:00 p.m., revealed the #20 Smoke Barrier contained a sprinkler pipe with a 1/4 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

2. Observation and interview on 06/02/2015 at 2:15 p.m., revealed the #20 Smoke Barrier contained a half inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier.

3. Observation and interview on 06/02/2015 at 2:30 p.m., revealed the smoke barrier near room #145 contained a sprinkler pipe with a one fourth inch gap above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 8 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 06/02/2015 at 12:55 p.m., revealed the facility failed to maintain the fire alarm system in the Main Lobby. This room contained a smoke detector with in three feet of an air diffuser.

2. Observation and interview on 06/02/2015 at 12:57 p.m., revealed the facility failed to maintain the fire alarm system in Room #2169. This room contained a smoke detector with in three feet of an air diffuser.

3. Observation and interview on 06/02/2015 at 1:05 p.m., revealed the facility failed to maintain the fire alarm system in Room #2045. This room contained a smoke detector with in three feet of an air diffuser.

4. Observation and interview on 06/02/2015 at 1:35 p.m., revealed the facility failed to maintain the fire alarm system in the corridor near Resident Room #2053. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observation and interview on 06/02/2015 at 1:40 p.m., revealed the facility failed to maintain the fire alarm system in Room #2160. This room contained a smoke detector with in three feet of an air diffuser.

6. Observation and interview on 06/02/2015 at 1:45 p.m., revealed the facility failed to maintain the fire alarm system in Storage Room #1101. This room contained a smoke detector with in three feet of an air diffuser.

7. Observation and interview on 06/02/2015 at 1:55 p.m., revealed the facility failed to maintain the fire alarm system in Lab Storage Room #1112. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of seven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 8 residents, staff, and visitors in the facility. The facility has a capacity of 25 with a census of 8.

Findings include:

1. Observation and interview on 06/02/2015 at 2:00 p.m., revealed the #20 Smoke Barrier contained a sprinkler pipe with a 1/4 inch gap above the lay in tile. According to the facility layout, this was a required barrier.

2. Observation and interview on 06/02/2015 at 2:15 p.m., revealed the #20 Smoke Barrier contained a half inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier.

3. Observation and interview on 06/02/2015 at 2:30 p.m., revealed the smoke barrier near room #145 contained a sprinkler pipe with a one fourth inch gap above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 8 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 06/02/2015 at 12:55 p.m., revealed the facility failed to maintain the fire alarm system in the Main Lobby. This room contained a smoke detector with in three feet of an air diffuser.

2. Observation and interview on 06/02/2015 at 12:57 p.m., revealed the facility failed to maintain the fire alarm system in Room #2169. This room contained a smoke detector with in three feet of an air diffuser.

3. Observation and interview on 06/02/2015 at 1:05 p.m., revealed the facility failed to maintain the fire alarm system in Room #2045. This room contained a smoke detector with in three feet of an air diffuser.

4. Observation and interview on 06/02/2015 at 1:35 p.m., revealed the facility failed to maintain the fire alarm system in the corridor near Resident Room #2053. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observation and interview on 06/02/2015 at 1:40 p.m., revealed the facility failed to maintain the fire alarm system in Room #2160. This room contained a smoke detector with in three feet of an air diffuser.

6. Observation and interview on 06/02/2015 at 1:45 p.m., revealed the facility failed to maintain the fire alarm system in Storage Room #1101. This room contained a smoke detector with in three feet of an air diffuser.

7. Observation and interview on 06/02/2015 at 1:55 p.m., revealed the facility failed to maintain the fire alarm system in Lab Storage Room #1112. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.