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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 60 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:45 AM, observed that the 2 hour fire separation wall was being moved. An error had been made in the location of the previous wall and the correction is now being made.

2. On July 25, 2012 at approximately 11:45 AM, observed that the facility could not verify the caulking around the conduit and wiring inside a conduit in the 2 hour separation is a listed fire stop material. this located near the Administration office.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 5 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 11:15 AM, observed the door to patient room A323 does not close to positive latch.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:15 AM, observed IT conduit penetrating the smoke barrier near the B-350 nurse station is not fire stopped and the wiring penetrating the conduit is not fire stopped.

2. On July 25, 2012 at approximately 10:30 AM, observed wires in conduit penetrating the electrical room near the B-350 nurse station are not fire stopped.

Based on observation the facility failed to provide lighting in accordance with the LSC section 18.2.8. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:05 AM, observed in stairway 8 at the 2nd floor landing that a light bulb is burned out.

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 60 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:45 AM, observed that the 2 hour fire separation wall was being moved. An error had been made in the location of the previous wall and the correction is now being made.

2. On July 25, 2012 at approximately 11:45 AM, observed that the facility could not verify the caulking around the conduit and wiring inside a conduit in the 2 hour separation is a listed fire stop material. this located near the Administration office.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 5 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 11:15 AM, observed the door to patient room A323 does not close to positive latch.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:15 AM, observed IT conduit penetrating the smoke barrier near the B-350 nurse station is not fire stopped and the wiring penetrating the conduit is not fire stopped.

2. On July 25, 2012 at approximately 10:30 AM, observed wires in conduit penetrating the electrical room near the B-350 nurse station are not fire stopped.

Based on observation the facility failed to provide lighting in accordance with the LSC section 18.2.8. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

1. On July 25, 2012 at approximately 10:05 AM, observed in stairway 8 at the 2nd floor landing that a light bulb is burned out.