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Based on observation and testing, the facility failed to provide doors that automatically close by zone or throughout the facility upon activation in accordance with 18.2.2.2.6, 19.2.2.2.6, and 7.2.1.8.2.

Findings include:

While inspecting smoke barrier doors on August 11, 2011 at 10:30 a.m., the surveyor observed that the smoke barrier doors, located next to the office area, did not close when the fire alarm was activated.

These deficient practices have the potential of effecting the entire facility.

The maintenance supervisor and the administrator were notified during the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect the entire facility.

Findings include:

While inspecting smoke barrier walls on August 11, 2011 at 10:00 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located near the office area had a unsealed penetration around electrical conduits and sprinkler piping.

This deficient practice has the potential of affecting 2 of 2 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 2 of 2 smoke compartments.

Findings include:

On August 11, 2011 at 11:30 a.m., the maintenance person and the the surveyor found the following hazardous areas to have unsealed penetrations:

1. Laundry room had 2 small penetration around electrical conduit.
2. Boiler room had numerous unsealed penetrations in the wall the connects with the hospital.
3. Central supply storage room had unsealed penetrations around the sprinkler piping.

This deficient practice has the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 1 of 2 smoke compartments.

Findings include:

On August 11, 2011 at 11:45 a.m., the maintenance person and surveyor found that the Senior Care Unit did not have a horn/strobe installed in the hallway.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff as all smoke compartments were affected.

Findings include:

On August 11, 2011 at 11:50 a.m., the administrator could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide doors that automatically close by zone or throughout the facility upon activation in accordance with 18.2.2.2.6, 19.2.2.2.6, and 7.2.1.8.2.

Findings include:

While inspecting smoke barrier doors on August 11, 2011 at 10:30 a.m., the surveyor observed that the smoke barrier doors, located next to the office area, did not close when the fire alarm was activated.

These deficient practices have the potential of effecting the entire facility.

The maintenance supervisor and the administrator were notified during the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect the entire facility.

Findings include:

While inspecting smoke barrier walls on August 11, 2011 at 10:00 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located near the office area had a unsealed penetration around electrical conduits and sprinkler piping.

This deficient practice has the potential of affecting 2 of 2 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 2 of 2 smoke compartments.

Findings include:

On August 11, 2011 at 11:30 a.m., the maintenance person and the the surveyor found the following hazardous areas to have unsealed penetrations:

1. Laundry room had 2 small penetration around electrical conduit.
2. Boiler room had numerous unsealed penetrations in the wall the connects with the hospital.
3. Central supply storage room had unsealed penetrations around the sprinkler piping.

This deficient practice has the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 1 of 2 smoke compartments.

Findings include:

On August 11, 2011 at 11:45 a.m., the maintenance person and surveyor found that the Senior Care Unit did not have a horn/strobe installed in the hallway.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff as all smoke compartments were affected.

Findings include:

On August 11, 2011 at 11:50 a.m., the administrator could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The maintenance supervisor and the administrator were notified during an exit conference.