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Based on observation and interview, the facility failed to maintain the smoke resistance of smoke barriers by sealing the space between penetrating items such as conduit, pipe, and tubing through the smoke barrier with a material capable of maintaining the smoke resistance of the smoke barrier in accordance with 8.3 in three (electrical room South of elevators, First floor electrical room and Second floor/South Stairwell) of nine areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next. The facility had a census of 39 patients on 04/06/2015. The findings were:

A. During a tour of the facility on 04/07/2015 at 1430, observations revealed two Electrical Metallic Tubing (EMT) conduits had penetrated the smoke barrier in the electrical room just south of the elevators. The facility failed to seal penetrations made by the conduit through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Director of Maintenance at the time of the tour.
B. During a tour of the facility on 04/08/2015 at 1030, observations revealed two penetrations made by EMT and polyvinyl chloride (PVC) conduit in the fire barrier above the fire rated doors on the first floor near the electrical room. The facility failed to seal the penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Technician at the time of the tour.
C. During a tour of the facility on 04/08/2015 at 1057, observations revealed two penetrations made by EMT conduit and copper tubing in the fire barrier above the ceiling above the fire rated doors on the second floor near the south stairwell. The facility failed to seal these penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Technician at the time of the tour.

Based on the inspection report of the automatic sprinkler system review and interview, the facility failed to maintain the system in reliable operating condition by not replacing the sprinkler system's backflow preventer. The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to insure the ability of the sprinkler system to function correctly in the event of a fire event. The facility had a census of 39 patients on 04/06/2015. The findings were:

A. Review of the inspection and maintenance records on 04/06/2015 at 1215 revealed the backflow preventer in the automatic sprinkler system needed to be replaced. The deficiency was discovered by the contractor during a routine inspection on 09/10/2009. The facility received a quote for the repairs on 07/14/2014. No evidence of the repair work being performed was found.
B. In an interview on 04/08/2015 at 1430 the Director of Maintenance verified that the quote had been received by the facility but the repair work had not been performed.

Based on the Preventative Maintenance Manual (PMM), fire damper testing documentation review and interview, the facility had failed to test the fire damper system every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to insure the reliability of the dampers to close in the event of a smoke or fire event. The facility had a census of 39 patients on 04/06/2015. The findings were:
A. Review of the PMM of the Fire Damper inspection documentation on 04/06/2015 at 1215 revealed there was a policy in place for the fire damper system to be tested every six years. However, no record of the system ever being tested was available.
B. In an interview on 04/08/2015 at 1430 the Director of Maintenance verified there was no documentation for the fire damper system testing.

Based on observation and interview, the facility failed to maintain the smoke resistance of smoke barriers by sealing the space between penetrating items such as conduit, pipe, and tubing through the smoke barrier with a material capable of maintaining the smoke resistance of the smoke barrier in accordance with 8.3 in three (electrical room South of elevators, First floor electrical room and Second floor/South Stairwell) of nine areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next. The facility had a census of 39 patients on 04/06/2015. The findings were:

A. During a tour of the facility on 04/07/2015 at 1430, observations revealed two Electrical Metallic Tubing (EMT) conduits had penetrated the smoke barrier in the electrical room just south of the elevators. The facility failed to seal penetrations made by the conduit through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Director of Maintenance at the time of the tour.
B. During a tour of the facility on 04/08/2015 at 1030, observations revealed two penetrations made by EMT and polyvinyl chloride (PVC) conduit in the fire barrier above the fire rated doors on the first floor near the electrical room. The facility failed to seal the penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Technician at the time of the tour.
C. During a tour of the facility on 04/08/2015 at 1057, observations revealed two penetrations made by EMT conduit and copper tubing in the fire barrier above the ceiling above the fire rated doors on the second floor near the south stairwell. The facility failed to seal these penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Technician at the time of the tour.

Based on the inspection report of the automatic sprinkler system review and interview, the facility failed to maintain the system in reliable operating condition by not replacing the sprinkler system's backflow preventer. The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to insure the ability of the sprinkler system to function correctly in the event of a fire event. The facility had a census of 39 patients on 04/06/2015. The findings were:

A. Review of the inspection and maintenance records on 04/06/2015 at 1215 revealed the backflow preventer in the automatic sprinkler system needed to be replaced. The deficiency was discovered by the contractor during a routine inspection on 09/10/2009. The facility received a quote for the repairs on 07/14/2014. No evidence of the repair work being performed was found.
B. In an interview on 04/08/2015 at 1430 the Director of Maintenance verified that the quote had been received by the facility but the repair work had not been performed.

Based on the Preventative Maintenance Manual (PMM), fire damper testing documentation review and interview, the facility had failed to test the fire damper system every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to insure the reliability of the dampers to close in the event of a smoke or fire event. The facility had a census of 39 patients on 04/06/2015. The findings were:
A. Review of the PMM of the Fire Damper inspection documentation on 04/06/2015 at 1215 revealed there was a policy in place for the fire damper system to be tested every six years. However, no record of the system ever being tested was available.
B. In an interview on 04/08/2015 at 1430 the Director of Maintenance verified there was no documentation for the fire damper system testing.