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Based upon observation and staff interview, the facility fails to assure that smoke barriers are constructed to provide at least a one half hour fire resistance rating. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 1 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 03/28/2012, 2:45 p.m., it is observed:

-- 1. Smoke partition wall in soiled linen room has unsealed penetrations around sprinkler piping.

Maintenance Staff A was present and acknowledged the findings. Maintenance Staff A stated that he would seal the penetrations using an approved method.

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 and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 03/28/2012, at 2:50 p.m., it is observed that the corridor door to the Boiler Room is not provided with a self-closing device.

Maintenance Staff A was present and acknowledged that no self-closing device is provided.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

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 6 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 03/28/2012, a review of records between 10:30 a.m. and 11:45 a.m., for the last four quarters, revealed the following:

-- 1. No documented weekly visual inspections of the dry-pipe automatic sprinkler system.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that the visual inspections are completed on a daily basis but that he was unaware of the need for weekly documentation.

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 smoke barriers are constructed to provide at least a one half hour fire resistance rating. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 1 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 03/28/2012, 2:45 p.m., it is observed:

-- 1. Smoke partition wall in soiled linen room has unsealed penetrations around sprinkler piping.

Maintenance Staff A was present and acknowledged the findings. Maintenance Staff A stated that he would seal the penetrations using an approved method.

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 and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings Include:

During the tour conducted on 03/28/2012, at 2:50 p.m., it is observed that the corridor door to the Boiler Room is not provided with a self-closing device.

Maintenance Staff A was present and acknowledged that no self-closing device is provided.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

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 6 of 6 smoke zones. The facility has a capacity of 49 in LTCU with a census of 48 and a capacity of 22 in the Hospital portion with a census of 9 at the time of the survey.

Findings include:

During the tour conducted on 03/28/2012, a review of records between 10:30 a.m. and 11:45 a.m., for the last four quarters, revealed the following:

-- 1. No documented weekly visual inspections of the dry-pipe automatic sprinkler system.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that the visual inspections are completed on a daily basis but that he was unaware of the need for weekly documentation.

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