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Based on observation and interview, the facility failed to maintain a corridor door to resist the passage of smoke per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2)

This deficiency could affect 25 residents.

Findings include:

On 04/18/2018, during a tour of the facility from 11:00 am to 3:00 pm, the surveyor observed the corridor door for room 229 had an approximately 1/4" unsealed penetration around the door handle (the door handle had been changed).

A member of the maintenance staff was present when this deficiency was identified

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Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

On 04/16/2018, during a tour of the facility from 11:00 am to 3:30 pm, the surveyor observed the following unsealed penetrations above the ceiling in smoke barriers:
1. A two inch unsealed conduit with gray and blue wires near the X-Ray Admission Office


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2. A two inch unsealed conduit with blue wires in the corridor wall near Dining Room

3. A one inch unsealed penetration around pipe near the Service Elevator

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

On 04/16/2018, during a tour of the facility from 11:00 am to 3:30 pm, the surveyor observed a one inch unsealed conduit with blue wires penetrating the smoke barrier above the ceiling near the smoke doors at the Scheduling Dept.

A member of the maintenance staff was present when this deficiency was identified.