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Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 18 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 1:52 pm surveyor #28616 observed in the CSTU-1 smoke compartment on the main level floor in the Court room B201, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) conduit sleeve approximately 1" diameter. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 2:39 pm surveyor #28616 observed in the CSTU-2 smoke compartment on the main level floor in the corridor side of Stair A243, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) 4" x 4" electrical junction box that did not have a cover. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director) and staff B (Buildings and Grounds Superintendent).

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Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect 5 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 at 12:50 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Workroom A156, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, and sealed wall penetrations. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 15 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 2:46 pm surveyor #28616 observed in the CSTU-3 smoke compartment on the main level floor in the Storage room A234, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 12:20 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Housekeeping room B107, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) 4" x 4" hole in the concrete block wall penetrated by (2) 1" conduits. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

3. On February 22, 2011 at 12:28 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Storage room A102, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) approximate 2" x 3" hole in the concrete block wall penetrated by (1) 1" conduit and (1) approximate 6" x 12" hole in the concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

4. On February 22, 2011 at 12:33 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Storage room A103, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) approximate 24" x 24" hole in the concrete block wall and (1) approximate 24" x 12" hole in the concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting. This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect 36 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 at 1:30 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Stair A123 discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 27 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 12:59 pm surveyor #28616 observed in the GTU-3 smoke compartment on the lower level floor in the Laundry room A140, that there was one or more unsealed holes near the ceiling. The hole(s) included an opening approximately 12" x 24" where the ceiling tile was not replaced following the installation of the dryer exhaust vent. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 2:33 pm surveyor #28616 observed in the CSTU-2 smoke compartment on the main level floor in the Communications room A245, that there was one or more unsealed holes near the ceiling. The hole(s) included approximately (6) 24" x24" ceiling tiles that were missing. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

______________________________________

Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 18 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 1:52 pm surveyor #28616 observed in the CSTU-1 smoke compartment on the main level floor in the Court room B201, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) conduit sleeve approximately 1" diameter. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 2:39 pm surveyor #28616 observed in the CSTU-2 smoke compartment on the main level floor in the corridor side of Stair A243, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) 4" x 4" electrical junction box that did not have a cover. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director) and staff B (Buildings and Grounds Superintendent).

______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect 5 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 at 12:50 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Workroom A156, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, and sealed wall penetrations. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 15 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 2:46 pm surveyor #28616 observed in the CSTU-3 smoke compartment on the main level floor in the Storage room A234, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 12:20 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Housekeeping room B107, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) 4" x 4" hole in the concrete block wall penetrated by (2) 1" conduits. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

3. On February 22, 2011 at 12:28 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Storage room A102, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) approximate 2" x 3" hole in the concrete block wall penetrated by (1) 1" conduit and (1) approximate 6" x 12" hole in the concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

4. On February 22, 2011 at 12:33 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Storage room A103, that penetration(s) were not sealed according to approved UL designs. The deficiency included (1) approximate 24" x 24" hole in the concrete block wall and (1) approximate 24" x 12" hole in the concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

______________________________________

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting. This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect 36 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 at 1:30 pm surveyor #28616 observed in the GTU-1 smoke compartment on the lower level floor in the Stair A123 discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

______________________________________

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect 27 of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On February 22, 2011 at 12:59 pm surveyor #28616 observed in the GTU-3 smoke compartment on the lower level floor in the Laundry room A140, that there was one or more unsealed holes near the ceiling. The hole(s) included an opening approximately 12" x 24" where the ceiling tile was not replaced following the installation of the dryer exhaust vent. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

2. On February 22, 2011 at 2:33 pm surveyor #28616 observed in the CSTU-2 smoke compartment on the main level floor in the Communications room A245, that there was one or more unsealed holes near the ceiling. The hole(s) included approximately (6) 24" x24" ceiling tiles that were missing. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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