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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 about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on February 6, 2013 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located at the emergency department had an unsealed penetrations around the air duct.

This deficient practice has the potential of affecting 2 of 4 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 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

On February 6, 2013 at 11:30 a.m., the maintenance person and the the surveyor found the following one hour enclosure to have penetrations:

1. The Central Storage Room had a penetration around the telephone cable was sealed with an unrated sealant.
2. The Boiler Room had unsealed penetrations around conduit and pipe that penetrated the interior wall.
3. Mechanical Room located in the rear of medical records storage had an unsealed penetration around piping that penetrated the elevator Equipment Room.

This deficient practice has the potential of affecting 2 of 4 smoke compartments.

The administrator and maintenance director were notified during the survey and in 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 about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on February 6, 2013 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located at the emergency department had an unsealed penetrations around the air duct.

This deficient practice has the potential of affecting 2 of 4 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 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

On February 6, 2013 at 11:30 a.m., the maintenance person and the the surveyor found the following one hour enclosure to have penetrations:

1. The Central Storage Room had a penetration around the telephone cable was sealed with an unrated sealant.
2. The Boiler Room had unsealed penetrations around conduit and pipe that penetrated the interior wall.
3. Mechanical Room located in the rear of medical records storage had an unsealed penetration around piping that penetrated the elevator Equipment Room.

This deficient practice has the potential of affecting 2 of 4 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.