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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 1 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 03/07/2012, it is observed:

-- 1. At 3:20 p.m., smoke barrier wall near the LTCU has gaps around wires and conduit which have not been sealed.

-- 2. At 3:40 p.m., smoke barrier wall in the Lab has gaps around wire and conduit which have not been sealed.

Maintenance Staff A was present and acknowledged the unsealed gaps. Maintenance Staff A stated that he would seal the gaps using approved methods.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity 16 of with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 3/7/12, a review of records between 1:30 p.m. and 2:30 p.m., for the last 5 quarters revealed the following:

-- 1. Fire Drills conducted within close proximity;

a. Drills for the 2nd shift, conducted between 7:28 p.m. and 8:07 p.m. for all 4 quarters of 2011.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting 3 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 03/07/2012, a review of records between 1:30 p.m. and 2:30 p.m., for the last 5 quarters, revealed the following:

-- 1. No documented monthly visual inspections of the automatic sprinkler system for the months of April through October, 2011.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he was unaware of the requirement for monthly visual inspections until November 2011. Maintenance Staff A stated that since he became aware of the requirement for monthly visual inspections the inspections have been completed each month.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 1 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 03/07/2012, it is observed:

-- 1. At 3:20 p.m., smoke barrier wall near the LTCU has gaps around wires and conduit which have not been sealed.

-- 2. At 3:40 p.m., smoke barrier wall in the Lab has gaps around wire and conduit which have not been sealed.

Maintenance Staff A was present and acknowledged the unsealed gaps. Maintenance Staff A stated that he would seal the gaps using approved methods.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity 16 of with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 3/7/12, a review of records between 1:30 p.m. and 2:30 p.m., for the last 5 quarters revealed the following:

-- 1. Fire Drills conducted within close proximity;

a. Drills for the 2nd shift, conducted between 7:28 p.m. and 8:07 p.m. for all 4 quarters of 2011.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting 3 of 3 smoke zones. The facility has a capacity of 16 with a census of 3 at the time of the survey.

Findings include:

During the tour conducted on 03/07/2012, a review of records between 1:30 p.m. and 2:30 p.m., for the last 5 quarters, revealed the following:

-- 1. No documented monthly visual inspections of the automatic sprinkler system for the months of April through October, 2011.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he was unaware of the requirement for monthly visual inspections until November 2011. Maintenance Staff A stated that since he became aware of the requirement for monthly visual inspections the inspections have been completed each month.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1