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Based on observation and interview, the facility failed to provide the proper interior finish in a hazard area in 1 of 3 smoke zones. Not providing the proper flame spread rating on the interior finish could effect all patients in the emergency care area due to smoke and fire, hindering proper evacuation. At the time of inspection no patients were in the area. Census was 1.

Findings are:

During the inspection on 04-02-10, at 1:37 P.M., it was observed that the interior finish was a fiber type spray on insulation. Interview with Maintenance "A" revealed that the insulation was sent in for testing and that it was not a foam based product but rather a cellulose material. A flame spread rating was unavailable for this product thus it could not be verified that it meets the required Class C Flame spread rating.

Based on observation and interview, the facility failed to provide proper smoke tightness at 3 of the 4 smoke barrier doors. Not providing the required smoke tightness puts all residents at risk of safe and clear evacuation. Census was 1.

Findings are:

During the survey on 04-02-10, between 12:30 P.M. and 2:15 P.M, it was observed that 3 of the 4 double doors in the smoke barrier between the patient zone and the other zones had a gap between the doors of over the allowed 1/8th inch. Interview with Maintenance "A" confirmed the Gap was over 1/8th inch.

Based on observation and interview with facility staff, the facility failed to maintain smoke resistance in hazardous areas. Failure to maintain these hazardous areas smoke tight puts all the residents of the facility in tow of three smoke zones which includes all the patient rooms, at risk should a fire develop in the hazard areas because of the spread of smoke. Resident census was 1.

Findings are:

During the survey on 04-02-10, the following was observed between 12:30 P.M and 2:15 P.M.
1. The Mechanical room had voids around pipes that penetrate the ceiling and the walls.
2. The Secure Storage room had voids in the ceiling.
3. The small Central Supply had a void around a pipe penetrating the ceiling.
Interview with Maintenance "A" confirmed there were voids which voided the smoke tightness required.

Based on record review and staff interview, the facility failed to test the automatic fire sprinkler system in accordance to NFPA 25. The lack of testing could lead to malfunction of the sprinkler system and could affect all residents, visitors, and staff if a fire should develop. Census was 1.

Findings are:
Record review on 04-02-10, at 1:16 P..M., revealed that the automatic fire sprinkler was not being tested on a quarterly basis as required in NFPA 25. Interview with Maintenance "A" confirmed that the testing was not being done.

Based on observation and interview, the facility failed to provide the proper interior finish in a hazard area in 1 of 3 smoke zones. Not providing the proper flame spread rating on the interior finish could effect all patients in the emergency care area due to smoke and fire, hindering proper evacuation. At the time of inspection no patients were in the area. Census was 1.

Findings are:

During the inspection on 04-02-10, at 1:37 P.M., it was observed that the interior finish was a fiber type spray on insulation. Interview with Maintenance "A" revealed that the insulation was sent in for testing and that it was not a foam based product but rather a cellulose material. A flame spread rating was unavailable for this product thus it could not be verified that it meets the required Class C Flame spread rating.

Based on observation and interview, the facility failed to provide proper smoke tightness at 3 of the 4 smoke barrier doors. Not providing the required smoke tightness puts all residents at risk of safe and clear evacuation. Census was 1.

Findings are:

During the survey on 04-02-10, between 12:30 P.M. and 2:15 P.M, it was observed that 3 of the 4 double doors in the smoke barrier between the patient zone and the other zones had a gap between the doors of over the allowed 1/8th inch. Interview with Maintenance "A" confirmed the Gap was over 1/8th inch.

Based on observation and interview with facility staff, the facility failed to maintain smoke resistance in hazardous areas. Failure to maintain these hazardous areas smoke tight puts all the residents of the facility in tow of three smoke zones which includes all the patient rooms, at risk should a fire develop in the hazard areas because of the spread of smoke. Resident census was 1.

Findings are:

During the survey on 04-02-10, the following was observed between 12:30 P.M and 2:15 P.M.
1. The Mechanical room had voids around pipes that penetrate the ceiling and the walls.
2. The Secure Storage room had voids in the ceiling.
3. The small Central Supply had a void around a pipe penetrating the ceiling.
Interview with Maintenance "A" confirmed there were voids which voided the smoke tightness required.

Based on record review and staff interview, the facility failed to test the automatic fire sprinkler system in accordance to NFPA 25. The lack of testing could lead to malfunction of the sprinkler system and could affect all residents, visitors, and staff if a fire should develop. Census was 1.

Findings are:
Record review on 04-02-10, at 1:16 P..M., revealed that the automatic fire sprinkler was not being tested on a quarterly basis as required in NFPA 25. Interview with Maintenance "A" confirmed that the testing was not being done.