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Based on observation and staff interview the facility is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/15/12 between 10:30 AM and 2:30 PM is observed there is sheet rock seams that are not sealed on the 100 hall side of the smoke barrier wall.

Maintenance Staff A was present and acknowledged the finding.

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 on observation, staff interview and record review, the facility did not assure a smoke damper is provided in a smoke barrier wall to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/15/12 between 10:30 AM and 2:30 PM it is observed there is no damper provided in the ventilation duct that runs through the smoke barrier wall. This has citation has had a waiver since the 2008 inspection.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: An approved damper designed to resist the passage of smoke shall be provided for each air transfer opening or duct penetration of a required smoke barrier per NFPA 101, 8.3.5.1. Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detectors in accordance with 1999 NFPA 72 and 2000 NFPA 101, 8.3.5.3

Based on record review and staff interview the facility failed to assure the generator is provided with all life safety components. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting 2 of 2 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

Based on observation on 2/15/12 it is observed there is no annunciator panel for the generator. This citation has had a waiver since the survey in 2008.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 out of 2 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

During the tour between 10:30 AM and 2:30 PM it is observed there is an open junction box above the ceiling tiles at the smoke barrier wall, nurse desk side of wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed